Tendon reconstruction is recommended for treating ankle instability

Long-term problems, multiple re-injuries may impede ligament reconstructions.

By Nicholas A. Abidi, MD
ORTHOPEDICS TODAY 2008; 28:88

Ankle instability is probably one of the most common sports injuries that we see each day in the United States: some 27,000 per day. It was the most common reason for a trip to the emergency room at one point and typically it is an inversion mechanism.

Nicholas A. Abidi

Overall, if it is instability and ankle sprain, what is the big deal? Our goal in nonoperative and operative treatment should be to prevent the occurrence of sprains, since they have been shown in the literature and in our practices to prevent the long-term development of arthritis in many cases.

I used to perform the Broström-Gould procedure. I had pretty good results with that in the first 5 or 6 years in practice and I am happy with that. But as I thought about long-term problems after 3 to 5 years of following these patients, I realized I could not reconstruct the ligaments effectively in many patients in the middle of surgery, and I didn’t necessarily have an alternative other than some nonanatomic tendon reconstructions.

I surveyed Canadian surgeons several years ago and they recently told me that because of the long waiting list for patients there, many of the surgeons have switched to tendon reconstruction procedures because they determined that the Broström-Gould didn’t always give good long-term results.

Many have also told me that they have to make this decision intraoperatively based on the quality of the tissue, and that they have to justify using anchors because the cost of implants or tendon grafts limits their use in their provinces.

Athletic population

I use tendon reconstruction in people who have failed bracing and are athletes. Many of them have more than 10 years of ankle instability as well as hyperextension, patellofemoral, elbow and shoulder issues. I have a highly athletic patient population, being near a military base on the West Coast, and I noticed that when I looked at the older series with the Broström-Gould technique that most patients had several reinjuries. Many patients obviously will have more reoccurring instability at 3 to 5 years, and I couldn’t explain it other than that their tissues had given up. Reconstructions were the same every time, and in the end, adding the Gould modifications didn’t make it a true anatomic reconstruction

I thought about how there are so many papers are going back to the 1960s that talk about ligament construction and how that progressed to interest in tendon reconstruction. The patients were unsatisfied with their ligament reconstructions.

There are many types of ankle ligament reconstructions, not all necessarily anatomic, and many downfalls, too. There are about 25 types of Christian-Snook procedures that cross the subtalar joint as many as three times, they were not anatomic and they were very stiff — perhaps worse than a fusion sometimes.

The Evans reconstruction that is an augmentation has been shown to create subtalar joint arthritis over the long term. The Colville procedure is not really anatomic because it keeps the peroneus brevis tendons attached and has limited inversion in some patients at long-term.

Anatomic reconstruction

Now switch to anatomic reconstruction. Coughlin and Younger are both high-volume surgeons and their papers are being published on using tendon graft with interference anchors in the heel and in the neck of the talus, where it maintains the 105° axis. The theory behind it is that the tendons are less likely to attenuate with time as much as the ligaments do.

Using anchors permits early motion. In the Broström-Gould approach, we were casting for 4 to 6 weeks, which led to its own morbidity and relied upon scar tissue in the procedures, which is sometimes relying on wishful thinking. In many cases, I found attenuation at long-term follow-up.

There are more recent anatomic ligament reconstructions. I try to avoid the ones using gracilis autograft from the knee because I think the graft is a bit bulky and requires accessing the medial knee for an ankle procedure. Nevertheless, investigators have found outstanding results in that they had one recurrence at the most in a large series of patients.

Technique

At the time I was doing the Colville procedure, I had a patient with no peroneus brevis ligament to reconstruct … only a peroneus longus and severe instability. So I took a strip of that and discovered that the length was perfect to reconstruct the ankle. The results were outstanding. I look forward to advancing the procedure by using it on other patients who I can study, using a linear incision along the course of the fibula that to see if it works as well.

I run a linear incision along the course of the fibula but above the superior retinaculum to about one-third of the peroneus longus, and remove it with a tendon stripper. I attach the graft to the origin of the calcaneofibular ligament (CFL) underneath the peroneal tendons through a tunnel in the fibula and then down to the anterior talofibular ligament (ATFL) and anchor it into the neck of the talus with an interference anchor. We then pull up the capsule, which we peeled off of the distal fibula, and suture it back to the fibula. We may supplement it with the Gould modification in high-demand patients. It is not necessarily as tight or as a solid as a primary Brostrum, but it closes the capsule and prevents impinging tissue.

Postoperative rehabilitation begins with nonweight-bearing for 2 weeks and then weight-bearing with a walker for 2 weeks, leg splints for 2 weeks and no long-term mobilization. For physical therapy, there are six to 12 physical therapy sessions.

I have entered patients who have chronic ankle instability with functional and demonstrable MRIs and variable demands into a new study. Most are of a high-performance military population on a military base, and quite a few are recreational athletes in our area. We used validated instruments prospectively with 30 patients and hope to finish collecting the data soon and validate that. So far, the SF12 scores improved in the physical and mental components.

Zero recurrance

The thing that I really noticed when I’ve talked to people who have used this procedure is that the incidence of recurrent injury in patients is flat zero. These guys are jumping over brick walls and jumping out of helicopters. The patients can swim, run marathons, participate in triathlons and return to regular full-service duty after the reconstruction, and they get back quickly.

They said that when they turned their ankle didn’t sprain, so that was a good thing. The downside seems to be numbness, which seems to go along with the Broström procedure and similar incisions as well. The worst of the patients had stiffness in the first 3 months. We mobilized them with cortisone to get them moving, and they seem to be doing pretty well in 6 months.

In summary, I found the Broström-Gould procedure sometimes to be less filling, while the anatomic tendon reconstruction to taste great. But, if you look at the overall evidence-based literature, essentially when you look at the comparison trials that were done with the older techniques and not these, there are no evidence-based comparison studies at level 2 or level 1 instances that compare these types of reconstructions, and some have to be done.

For more information:

• Nicholas A. Abidi, MD, can be reached at Santa Cruz Orthopaedic Institute, 1505 Soquel Drive, Suite 12, Santa Cruz, CA 95065; 831-475-4024; e-mail: nabidi@comcast.net. He has no direct financial interest in any product or company mentioned in the article.

Reference:

• Abidi NA. Tendon reconstruction. Presented as part of the Ankle Instability Debate at the 38th Annual Winter Meeting of the American Orthopaedic Foot and Ankle Society. March 8, 2008. San Francisco.